Provider Demographics
NPI:1336812700
Name:ALLEN, NATHAN ROBERT ALEXANDER (RPH)
Entity Type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:ROBERT ALEXANDER
Last Name:ALLEN
Suffix:
Gender:M
Credentials:RPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9129 LAKESHORE DR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-1532
Mailing Address - Country:US
Mailing Address - Phone:662-671-9551
Mailing Address - Fax:
Practice Address - Street 1:2996 CHURCH RD E
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9825
Practice Address - Country:US
Practice Address - Phone:662-349-4418
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-30
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSE-100286183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist